REGISTER

TRAUMA HEALING - YOUNG WOMEN/YOUNG MEN PROGRAM REGISTRATION

Step 1 of 4

Your healing program booking will be confirmed once we have received:1. your registration form and2. your initial registration fee or payment.

To avoid disappointment, PLEASE only make travel or work arrangements after you have received your confirmation.

Before you start to complete practical information you will need to read and agree to our key safety principles. This is to ensure that Heal For Life is a safe place for all. Please contact us if you have any questions.

KEY SAFETY PRINCIPLES1. I agree to keep totally confidential anything I hear about other people during the week. You need to agree to keep people's identities, and stories confidential. This is so people can feel safe to be vulnerable and honest with themselves and others.

2. I agree to NOT bring any alcohol or illicit drugs to the healing week. We ask that you are "clean" for at least a month before your visit so you can feel your feelings, stay grounded and have no possibility of withdrawals during the healing week. If you are taking prescription medication (e.g. anti-depressants) DO NOT STOP taking them immediately prior or while you are here. Please bring your prescribed medication with you. You must be responsible for looking after your own medication. Please clearly label your medication with your name and the used by date.

3. I agree to not leave the property during the healing week. If you leave the property for any reason during the week you will be unable to complete that particular healing week. This is because we have found that taking breaks from the Healing Week is disruptive and can distract not just you but also your fellow guests from healing. You will be welcome to attend a healing week at another time.

4. I am committed to my healing and will avoid distractions. It's important to be here for yourself and not to satisfy family members or others. We ask that you avoid distractions so that you can enter into the healing week, and receive the maximum benefit. For this reason there are no TVs, newspapers, radios, magazines or games. We ask that you do not bring novels, laptops or bring any of your usual work or study with you as it might distract you, and others, from healing.

5. I understand and accept that I will not be able to keep or use my mobile phone during the week. Group safety is our first concern and we have found that if any guest uses a mobile phone during the week, it breaks the sense of safety for everyone. We have also found that it is hard to concentrate on yourself if you are phoning family, friends or work colleagues. We will therefore ask you to leave your mobile phone in our care during the week. Of course if there is a special need, we are happy to discuss this with you. As you will not be able to use your mobile as an alarm or to play music, we suggest you bring an alarm clock with you. IPod or MP3 players are only to be used at night to help you sleep. Earphones to be used at all times.

6. I understand that if I self harm I may be asked to leave. Self-harm is a way some of us abuse ourselves. Our healing program is designed to help you develop alternative effective coping mechanisms.

7. I understand that sexualised behaviour is inappropriate here. Sexual behaviours are not just about sex. They include any talk, touch, questions, conversations and interests which relate to sexuality and relationships. So that everyone can feel safe and focus on their healing, we ask that there be no sexualised behaviour including nudity or partial nudity; no sexual activity; kissing; flirting; sexual jokes or innuendos during the healing program.

8. I understand that if I behave in an unsafe manner I may be asked to leave. I have provided the name of an emergency contact person you can contact if this is the case. Although very rare, occasionally we have had to ask guests to leave as abuse of any kind is not tolerated. This includes swearing or shouting at someone, derogatory comments or using intimidating body language. Heal For Life Foundation is committed to providing a safe place for survivors who did not experience a sense of safety in childhood. It is vital that all members of the group work together peacefully and lovingly and take full responsibility for their part in any conflict.

Name*

FirstLast

I agree with all of the key safety principles above*

Click in the box to indicate yes you agree and click Next to continue your registration

If there are any cultural or religious observances you adhere to, please speak with the facilitator on arrival to the program. Please fill in all of the below questions so that we can provide the best possible service to you.

Nominated EMERGENCY CONTACT PERSON to be contacted if you leave before the end of the program or in an emergency.

Name*

Relationship to you*

His / Her Phone Number*

Have you had a drug / alcohol / gambling issue?*

If 'yes', please specify

Alcohol

Illicit drugs

Non-prescription Medication

Gambling

Have you been clean for 30 days?*

Will you be taking Methadone during the program?*

Do you have any allergies or specific dietary needs?*

If you feel it would be helpful for us to know, please note any mental health diagnoses

Bipolar

PTSD

Depression

Anxiety

Dissociative Identity Disorder

Schizophrenia

Borderline Personality Disorder

Depersonalisation Disorder

Other

Other*

Do you take any medication? (please bring it with you)*

No

Antidepressant

Mood Stabiliser

Anti Anxiety

Blood Pressure

Anti-Psychotic

Asthma

Epilepsy

Methodone

Sleeping Pills

Other

In the last 6 months have you been admitted to a psychiatric hospital?*

In the last 6 months have you recieved counselling?*

No

Psychologist

Psychiatrist

Counsellor

Alternative

To enable us to help you better, you may wish to let us know the type of trauma you are a survivor of:

Physical

Emotional

Sexual

Spiritual

Neglect

SRA

Poor Parenting

Bullying

Abandonment

Incest

Domestic Violence

Early Childhood Illness

Divorce of parent

Death of a parent and/or sibling

Child Refugee

Child in State Care

Torture

In the last 3 months, have you experienced problems in the following areas?*

Moods

Eating or Appetite

Sleeping

Trouble thinking clearly; understanding or concentrating

Speech

Missing Time

Suicidal Thoughts

Self Harm

Self Neglect

Aggression or Violence

Threats to or from others

Legal or police issues

Please note down what your goals might be for the week, eg what would you like to change about yourself or your life by attending the program?*

Your healing program will be con­firmed once you have sent your Initial Registration Fee payment.

PLEASE do not make any travel or work arrangements until you have received a letter or email confirmation from us.

Cancellation / Deferral:

We often have a waiting list for our programs. If you cancel, defer or do not come to a confirmed place this may prevent someone else from attending. Please tick that you have read and understand the following:

1. I accept that if I cancel or defer after confirmation has been received, my Initial Registration Fee is not refundable.

2. If I cancel/ defer within 7 days of the program start date I understand that I am committed to complete the payment option I have chosen as it will have prevented someone else from attending.

3. If I choose to leave the program or if I am asked to leave prior to its completion I understand that I am committed to complete the payment option I have chosen.

Yes*

I have read and understand the above cancellation/deferral details.

The following fee covers accommodation, all workshops and workshop materials during the program. Heal For Life is committed to making our program available to anyone in need regardless of current income. However we receive no Government funding and we wish to remain independent. We are very grateful to those who can afford to pay the whole fee.

We offer monthly payments to make it easier for you. If however you have any problems with any of these options please call us on 02 4998 6003.

The following fee covers 5 nights’ accommodation and all workshops during the program. We wish to keep our program as affordable as possible and trust you will opt to pay the fee that best meets your financial situation.

Please select one of the following:*

Upfront Payment*

Price:$ 2,400.00Quantity:

Pay via direct deposit:

Greater Building Society Ltd - Heal For Life Adult Centre

Account No 718253683

BSB 637000

Once we have received your initial registration fee and registration details, we can confirm your place in the program.

Sponsored places – on each programme we have a limited number of sponsored places which can cover all or part of the total fee - If this would better fit your financial circumstances please contact the Office.